(Echinacea angustifolia, Echinacea pallida, Echinacea purpurea) Natural Standard® Patient Monograph, Copyright © 2014 (www.naturalstandard.com). All Rights Reserved. Commercial distribution prohibited. This monograph is intended for informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions. Common Brand Name(s) Imboost Background Echinacea species belong to the aster family (Asteraceae) that originated in eastern North America. Of the nine identified species, only three are used as medicine. The roots and herbs of the species have been studied for potential immune benefits. Echinacea has been taken by mouth in Europe and the United States to help prevent or treat the common cold. In the United States, echinacea sales are thought to make up 10 percent of the dietary supplement market. Although much research has been done on the potential cold-fighting effects of echinacea, results are conflicting. There have been reports of a lack of benefit and rash caused by echinacea in children. Early studies looking at the potential benefits of echinacea for herpes and radiation poisoning have found a lack of evidence. Applying echinacea juice to the skin has been suggested for wound healing, and taking echinacea by mouth or injecting it has been suggested for vaginal yeast infections. However, clear evidence is lacking in these areas. Echinacea use has been discouraged in people who have autoimmune disease. However, more research is needed before further conclusions can be made. Related terms Alkamides, alkylamides, American coneflower, Asteraceae (family), black sampson, black susan, caffeic acid derivatives, caffeoyl derivatives, cichoric acid and polysaccharides, cock-up-hat, combflower, compositae, cynarin, dodeca-2E,4E,8Z,10Z(E)-tetraenoic acid isobutylamide, dodecanoic acid derivatives, EC31J0, Echinacea® (Strong Nature, Serbia), Echinacea angustifolia, Echinacea laevigata, Echinacea Moench, Echinacea pallida, Echinacea Plus®, Echinacea purpurea, Echinacea purpurea L. Moench, Echinacea simulata, Echinacea tennesseensis, Echinacin®, Echinacin® EC31, echinacoside, Echinaforce®, Echinaforce® Forte, EchinaFresh® (Enzymatic Therapy, Green Bay, WI), Echinaguard®, Echinilin® (Factors R & D Technologies, Burnaby, BC, Canada), echino (Greek), EFLA® 894, glycoconjugates, hedgehog, hydrophilic polysaccharides, Igelkopf (German), Indian head, Kansas snake root, Kegelblume (German), narrow-leaved purple coneflower, N-isobutyldodeca-2E,4E,8Z,10Z-tetraenamide, Pascotox®, pentadeca-(8Z,13Z)-dien-11-yn-2-one, Polinacea™, polysaccharide, purple coneflower, red sunflower, rudbeckia, SB-TOX, scurvy root, sea urchin, snakeroot, solhat (Danish), sonnenhut (German), sun hat, undeca-2-ene-8,10-diynoic acid isobutylamide, undecanoic acid derivatives, unsaturated N-alkylamide lipids. Combination product examples: ChizukitTM, an echinacea product that contains 50mg/mL of the extract of the upper plant parts of Echinacea purpurea and roots of Echinacea angustifolia, 50mg/mL of propolis, and 10mg/mL of vitamin C; Cold-X® (Vitamin C 100mg, Echinacea purpurea root extract 20.1mg, eucalyptus leaf extract 12.3mg, fennel seed extract 10.3mg); Kan Jang® (Adhatoda vasica, Echinacea purpurea, and Eleutherococcus senticosus); Esberitox® liquid (ethanolic-aqueous extracts of herba Thuja occidentalis 2mg, radix Echinacea 7.5mg, and radix Baptisia tinctoria 10mg); Esberitox® tablets (vitamin C 20mg, Thuja occidentalis 2mg, radix Echinacea 7.5mg, and radix Baptisia tinctoria 10mg); the transmucosal herbal periodontal patch, provided by Izun Pharmaceuticals (New York, NY) (plant extracts from Centella asiatica (gotu kola), Echinacea purpurea, and Sambucus nigra (elderberry)); Erbavita® (Andrographis paniculata, Echinacea, grapefruit, papaya, Tabebuia, and Uncaria); Imoviral® Junior (an herbal combination therapy that contains Echinacea angustifolia, arabinogalactan, vitamin C, beta-glucan, and zinc). Dosing The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy. Adults (18 years and older) To treat anxiety, 20-40 milligrams of echinacea have been taken by mouth daily for seven days. To improve exercise performance, five 400 milligram doses of echinacea have been taken by mouth four times daily for 28 days. A dose of 8,000 milligrams of echinacea has been taken by mouth once daily for 28 days. To stimulate the immune system, five 400 milligram doses of echinacea have been taken by mouth four times daily for 28 days. A total of eight doses of Echinilin® (5 milliliters each) have been taken by mouth in a single day at onset of two symptoms of common cold, followed by three doses of 5 milliliters daily for six days. A combination dose containing 675 milligrams of Echinacea purpurea and 600 milligrams of Echinacea angustifolia has been taken by mouth twice daily for 14 days. A dose of 780 milligrams of Echinacea purpurea whole herb extract and 680 milligrams of ultrarefined Echinacea purpurea whole herb and Echinacea angustifolia root has been taken by mouth in two capsule doses twice daily. A dose of 908 milligrams of Echinacea purpurea whole herb extract, 464 milligrams of Echinacea purpurea whole herb, and 36 milligrams of Echinacea angustifolia root has been taken by mouth in two capsule doses twice daily. A dose of 7.5 milliliters of alcohol extract of Echinacea purpurea has been taken by mouth twice daily for seven days. To treat low white blood cell count caused by radiation, two Echinacea® tablets (275 milligrams each) have been taken by mouth twice daily for two weeks. To prevent the common cold in adults and children, doses of 176-300 milligrams of Echinacea purpurea or 300 milligrams of Echinacea angustifolia have been taken by mouth three times daily for 1-8 weeks before a virus challenge, followed by continuation of treatment for five or seven days. A 1.5 milliliter tincture containing the equivalent of 300 milligrams of Echinaceaangustifolia root has been taken by mouth three times daily for seven days before experimental infection or starting on the day of experimental infection and continuing for five days. A dose of 4 milliliters of echinacea juice has been taken by mouth twice daily for eight weeks. Pressed juice of Echinacea purpurea (Echinacin® EC31) has been taken by mouth once daily for 28 days. A dose of 2,400 milligrams (0.9 milliliters) of Echinaforce® has been taken by mouth daily in three divided doses, then increased to 4,000 milligrams daily in five divided doses for a total of four months. A dose of 200 milligrams of Polinacea® has been taken by mouth daily for 15 days, then reduced to 100 milligrams daily for 15 days, then finally reduced to 100 milligrams every other day for 60 days. To treat the common cold in adults, experts often suggest: 500-1,000 milligrams of echinacea three times daily for 5-7 days (with 900 milligrams daily shown to have more benefit than 450 milligrams daily); a dose of 6-9 milliliters of echinacea juice daily in divided doses for 5-7 days; a dose of 0.75-1.5 milliliters of tincture, gargled then swallowed, 2-5 times daily for 5-7 days (with daily dose equivalent to 900 milligrams of dried echinacea root); and for echinacea tea, typically 2 teaspoons (4 grams of powdered echinacea herb) simmered in boiling water for 10 minutes, taken daily for 5-7 days. Eight doses of 5 milliliters of Echinacea purpurea extract (Echinilin®), diluted with half a glass of water, have been taken by mouth on the first day of cold symptoms, with three doses taken on days 2-7. Echinilin® has also been taken by mouth in 4 milliliter doses for seven days. Echinaforce® (6.78 milligrams of Echinacea purpurea extract) and a 7X concentration (48.27 milligrams) has been taken by mouth. Twenty drops of Echinaguard® (Echinacea purpurea sap) has been taken by mouth in water every two hours for the first day, then three times daily for up to 10 days. Echinacea pallida root has been taken by mouth as 90 drops daily over 8-10 days. Five to six cups of Echinacea Plus® tea (equivalent to 1.275 milligrams of dried herb and root per tea bag) have been taken by mouth on the first day and reduced by one cup daily for the next five days. A dose of 900 milligrams of Pascotox® (Echinacea pallida root) has been taken by mouth daily for 8-10 days. A dose of 1 milliliter of Echinacea angustifolia or Echinacea purpurea root extract in 30 percent alcohol has been taken by mouth twice daily for 12 weeks. The pressed juice of Echinacea purpurea (Echinacin® EC31) has been taken by mouth for 28 days. A mixture of unrefined Echinacea purpurea herb (25%) and root (25%) plus Echinacea angustifolia root (50%) has been taken by mouth in 1 gram doses six times on the first day of symptoms, then three times daily on each additional day of illness, for up to 10 days. Echinacea tablets containing 675 milligrams of Echinacea purpurea and 600 milligrams of Echinacea angustifolia root extracts have been taken by mouth in two tablet doses four times daily for one day, followed by one tablet doses four times daily for four days. To treat mild eye inflammation, 150 milligrams of Echinacea purpurea have been taken by mouth twice daily as an add-on therapy. To promote wound healing, experts often suggest using a 15 percent pressed herb juice applied to the skin daily. For cancer, 300 milligrams per meter squared of cyclophosphamide have been given through an intravenous (IV) tube every 28 days, 60 milligrams per meter squared of Echinacin® have been injected into the muscle, and 30 milligrams per meter squared of thymostimulin have been injected into the muscle on days 3-10 after cyclophosphamide, then twice weekly. A solution containing 2 milligrams of an echinacea polysaccharide has been given through IV once daily, starting three days before chemotherapy and continuing for 10 days. In general, injectable forms of echinacea are no longer approved for use in Germany and are not available commercially, as severe reactions have been reported. Children (under 18 years old) Increased risk of rash has been reported after the use of echinacea for cold symptom treatment in children aged 2-11 years. The Medicines and Healthcare Products Regulatory Agency (MHRA), European Herbal Medicinal Products Committee (HMPC), and the UK Herbal Medicines Advisory Committee (HMAC) warn that children under 12 should avoid echinacea due to the risk of severe allergic reaction. However, Echinaforce® Tablets and Echinaforce® Echinacea Drops, which are taken by mouth, have been approved for children under 12. To prevent the common cold, 100 milligrams of Monoselect® or Be Total Plus has been taken by mouth daily for 30 days, then reduced to 100 milligrams of Polinacea® every other day for the next 60 days. To treat whooping cough in children 14 years and younger, 1-2 milliliters of squeezed aqueous extract (0.1 grams per 2 milliliters) have been injected into the muscle twice daily for 3-21 days. However, safety information on injecting echinacea into the muscle is limited and should be used with caution. Echinacea preparations given through IV feeding tubes are no longer approved for use in Germany and are not available commercially, as severe reactions have been reported. Safety The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects. Allergies Avoid in people who are allergic or sensitive to echinacea, its parts, or any members of the Asteraceae or Compositae family (such as chrysanthemums, daisies, marigolds, and ragweed). People who have asthma or atopy (tendency for allergic asthma, eye and skin allergies, food allergy, or hay fever) may be more likely to have allergic reactions after taking echinacea by mouth or applying it to the skin. Hives, itching, low blood pressure, lung spasm, rash, severe allergic reaction, shock, skin redness, and swelling under the skin have been reported with echinacea use. Increased risk of rash has been reported after the use of echinacea for cold symptom treatment in children aged 2-11 years. Side Effects and Warnings Echinacea is likely safe when taken by mouth or applied to the skin in suggested doses for up to eight weeks. Echinacea is thought to be possibly safe when used in children and in pregnant women if taken as directed. However, more safety information is needed. Use cautiously in people who have heart disease. Echinacea may cause abnormal or irregular heartbeat. Caution is advised in people who are taking drugs that may increase the risk of bleeding. Dosing adjustments may be necessary. Use cautiously in people who have skin disorders. Echinacea may cause burning sensations, hives, itching, rashes, and skin redness. Use cautiously when used in injectable form, especially for people who have diabetes, according to experts. Use cautiously in people who are taking agents that may affect the immune system, agents that may affect the liver’s processing of drugs, amoxicillin, corticosteroids, or kava. Use tinctures cautiously in pregnant women and alcoholics, and in people who are taking disulfiram or metronidazole. Use cautiously in people who have or are at risk of liver disorders or are taking a large amount of echinacea. Echinacea may cause liver damage. Use cautiously in people who are taking agents that may be toxic to the liver (including anabolic steroids, amiodarone, methotrexate, and ketoconazole). Echinacea may cause liver inflammation. Use cautiously in children who have colds. Echinacea may increase the risk of ear infection. Use cautiously when used long-term. Long-term echinacea may cause reduced white blood cell count. Echinacea may cause a blood disorder in which blood clots form in small blood vessels, leading to a low platelet count. Use cautiously in people who have abnormally high iron levels, abnormal white blood cell count, AIDs, arthritis or other joint diseases, atopy (tendency for allergic asthma, eye and skin allergies, food allergy, or hay fever), autoimmune diseases, cancer, chronic headaches or migraines, collagen disease, HIV, kidney disease, mental disorders (anxiety or nervousness), multiple sclerosis, sleep disorders, stomach problems, and tuberculosis. Avoid in people who are allergic or sensitive to echinacea, its parts, or any members of the Asteraceae or Compositae family (such as chrysanthemums, daisies, marigolds, and ragweed). Avoid using in combination with anesthesia. Avoid using in people who are preparing to undergo transplant surgery. Echinacea may also cause anxiety and nervousness, bad taste, bronchitis, constipation, diarrhea, dizziness, dry throat, dry mouth, fatigue, headache, heartburn, joint pain, kidney failure, mild drowsiness, mild nausea, mouth irritation, numb tongue, pemphigus vulgaris (autoimmune disease causing blistering, sore skin), sleep problems, sperm motility, stomach pain, upset stomach, and vomiting. Pregnancy and Breastfeeding Research suggests that echinacea is one of the most commonly used herbal supplements in women before and during pregnancy. However, safety information is limited on the use of echinacea in breastfeeding women, pregnant women, or women who are trying to become pregnant. Interactions Interactions with Drugs Echinacea may interact with drugs that increase the risk of bleeding. Some examples include aspirin, anticoagulants (“blood thinners”) such as warfarin (Coumadin®) or heparin, anti-platelet drugs such as clopidogrel (Plavix®), and non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®). Echinacea may interfere with the way the body processes certain drugs using the liver’s “cytochrome P450” enzyme system. As a result, the levels of these drugs may be increased in the blood, and may cause increased effects or potentially serious adverse reactions. People using any medications should check the package insert, and speak with a qualified healthcare professional, including a pharmacist, about possible interactions. Echinacea may interact with agents that are cleared from the body by the kidneys, agents that affect the immune system, agents toxic to the liver, agents that increase light sensitivity, agents that treat muscle spasms, agents that treat retroviral infections (HIV), anesthesia, antibiotics, anticancer agents, anti-inflammatories, antiviral agents, anxiety agents, caffeine, cardiac glycosides, corticosteroids, dental agents, disulfiram (Antabuse®), econazole nitrate (Spectazole®), metronidazole (Flagyl®), P-glycoprotein-regulated agents, and steroids. Interactions with Herbs and Dietary Supplements Echinacea may interact with herbs and supplements that are believed to increase the risk of bleeding. Multiple cases of bleeding have been reported with the use of Ginkgo biloba, and fewer cases with garlic and saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases. Echinacea may interfere with the way the body processes certain herbs or supplements using the liver’s “cytochrome P450” enzyme system. As a result, the levels of other herbs or supplements may become too high in the blood. It may also alter the effects that other herbs or supplements possibly have on the P450 system. Echinacea may interact with anesthesia, antibacterials, anticancer herbs and supplements, anti-inflammatory herbs and supplements, antioxidants, antivirals, astralagus, caffeine-containing herbs and supplements, cardiac glycosides, dental herbs and supplements, glycyrrhiza, herbs and supplements that are cleared from the body by the kidneys, herbs and supplements that affect the immune system, herbs and supplements toxic to the liver, herbs and supplements that increase light sensitivity, herbs and supplements that treat anxiety, herbs and supplements that treat muscle spasms, kava, P-glycoprotein-regulated agents, and vitamins.